1
|
Valderrama CE, Ketabi N, Marzbanrad F, Rohloff P, Clifford GD. A review of fetal cardiac monitoring, with a focus on low- and middle-income countries. Physiol Meas 2020; 41:11TR01. [PMID: 33105122 PMCID: PMC9216228 DOI: 10.1088/1361-6579/abc4c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus ‘best practices’ of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.
Collapse
Affiliation(s)
- Camilo E Valderrama
- Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | | | | |
Collapse
|
2
|
Liston R, Sawchuck D, Young D. No. 197b-Fetal Health Surveillance: Intrapartum Consensus Guideline. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e298-e322. [PMID: 29680084 DOI: 10.1016/j.jogc.2018.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada. OPTIONS Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: LABOUR SUPPORT DURING ACTIVE LABOUR: RECOMMENDATION 2: PROFESSIONAL ONE-TO ONE CARE AND INTRAPARTUM FETAL SURVEILLANCE: RECOMMENDATION 3: INTERMITTENT AUSCULTATION IN LABOUR: RECOMMENDATION 4: ADMISSION FETAL HEART TEST: RECOMMENDATION 5: INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME: When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). RECOMMENDATION 6: DIGITAL FETAL SCALP STIMULATION: RECOMMENDATION 7: FETAL SCALP BLOOD SAMPLING: RECOMMENDATION 8: UMBILICAL CORD BLOOD GASES: RECOMMENDATION 9: FETAL PULSE OXIMETRY: RECOMMENDATION 10: ST WAVEFORM ANALYSIS: RECOMMENDATION 11: INTRAPARTUM FETAL SCALP LACTATE TESTING.
Collapse
|
3
|
Liston R, Sawchuck D, Young D. N° 197b-Surveillance du bien-être fœtal : Directive consensus d'intrapartum. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e323-e352. [PMID: 29680085 DOI: 10.1016/j.jogc.2018.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
4
|
Prediction of intrapartum fetal hypoxia considering feature selection algorithms and machine learning models. Health Inf Sci Syst 2019; 7:17. [PMID: 31435480 DOI: 10.1007/s13755-019-0079-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022] Open
Abstract
Introduction Cardiotocography (CTG) consists of two biophysical signals that are fetal heart rate (FHR) and uterine contraction (UC). In this research area, the computerized systems are usually utilized to provide more objective and repeatable results. Materials and Methods Feature selection algorithms are of great importance regarding the computerized systems to not only reduce the dimension of feature set but also to reveal the most relevant features without losing too much information. In this paper, three filters and two wrappers feature selection methods and machine learning models, which are artificial neural network (ANN), k-nearest neighbor (kNN), decision tree (DT), and support vector machine (SVM), are evaluated on a high dimensional feature set obtained from an open-access CTU-UHB intrapartum CTG database. The signals are divided into two classes as normal and hypoxic considering umbilical artery pH value (pH < 7.20) measured after delivery. A comprehensive diagnostic feature set forming the features obtained from morphological, linear, nonlinear, time-frequency and image-based time-frequency domains is generated first. Then, combinations of the feature selection algorithms and machine learning models are evaluated to achieve the most effective features as well as high classification performance. Results The experimental results show that it is possible to achieve better classification performance using lower dimensional feature set that comprises of more related features, instead of the high-dimensional feature set. The most informative feature subset was generated by considering the frequency of selection of the features by feature selection algorithms. As a result, the most efficient results were produced by selected only 12 relevant features instead of a full feature set consisting of 30 diagnostic indices and SVM model. Sensitivity and specificity were achieved as 77.40% and 93.86%, respectively. Conclusion Consequently, the evaluation of multiple feature selection algorithms resulted in achieving the best results.
Collapse
|
5
|
Significant reduction in umbilical artery metabolic acidosis after implementation of intrapartum ST waveform analysis of the fetal electrocardiogram. Am J Obstet Gynecol 2019; 221:63.e1-63.e13. [PMID: 30826340 DOI: 10.1016/j.ajog.2019.02.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 01/17/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although the evidence regarding the benefit of using ST waveform analysis of the fetal electrocardiogram is conflicting, ST waveform analysis is considered as adjunct to identify fetuses at risk for asphyxia in our center. Most randomized controlled trials and meta-analyses have not shown a significant decrease in umbilical metabolic acidosis, while some observational studies have shown a gradual decrease of this outcome over a longer period of time. Observational studies can give more insight into the effect of implementation of the ST technology in daily clinical practice. OBJECTIVE To evaluate the change in frequency of perinatal intervention and adverse neonatal outcome after the implementation of ST waveform analysis of the fetal electrocardiogram from 2000 to 2013. STUDY DESIGN This retrospective longitudinal study was conducted in a tertiary referral center. A total of 19,664 medium- and high-risk singleton pregnancies with fetuses in cephalic presentation, a gestational age of ≥36 weeks, and the intention to deliver vaginally were included. ST waveform analysis of the fetal electrocardiogram was implemented in the year 2000 and by 2010 all deliveries were monitored using this technology. Data were collected on the following perinatal outcomes: fetal blood sampling, mode of delivery, umbilical cord blood gases, Apgar scores, neonatal encephalopathy, and perinatal death. Longitudinal trend analysis was used to detect changes over time in all deliveries monitored by cardiotocography either alone or in adjunct to ST waveform analysis of the fetal electrocardiogram. Logistic regression was used to correct for possible confounders. RESULTS The umbilical artery metabolic acidosis rate declined from 2.5% (average rate of 2000 + 2001 + 2002) to 0.4% (average of 2011 + 2012 + 2013) (P < .001), which represents an 84% decrease. This decrease largely occurred between 2006 and 2008, during the Dutch randomized trial on fetal electrocardiogram ST waveform analysis. At this time, approximately 20% of deliveries were monitored using this method. Furthermore, there were significant reductions in fetal blood sampling rate (P < .001). Overall cesarean and vaginal instrumental deliveries decreased significantly (P < .001), but not for fetal distress. There were no changes in the Apgar scores. The incidence of neonatal encephalopathy was significantly lower in the second part of the study (odds ratio 0.39, 95% confidence interval 0.17-0.89). CONCLUSION There was an 84% decrease in the incidence of umbilical artery metabolic acidosis in all deliveries between 2000 and 2013. The neonatal encephalopathy rate, fetal blood sampling rate, and the total number of cesarean and vaginal instrumental deliveries also decreased.
Collapse
|
6
|
Vannucchi CI, Silva LG, Lúcio CF, Veiga GAL. Oxidative stress and acid-base balance during the transition period of neonatal Holstein calves submitted to different calving times and obstetric assistance. J Dairy Sci 2018; 102:1542-1550. [PMID: 30594373 DOI: 10.3168/jds.2018-14754] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 10/30/2018] [Indexed: 11/19/2022]
Abstract
During the neonatal period, constant adaptations to the extrauterine environment are required. These adaptations are made impossible or hindered when unexpected obstetrical events take place. This study aimed to identify clinical changes of vitality, metabolic and acid-base balance, and oxidative stress of newborn calves born to assisted dams that experienced different durations of calving. A prospective and observational study was conducted with 44 Holstein calves allocated to 3 groups according to the duration of calving: 2 h (n = 16), 2-4 h (n = 16), and >4 h (n = 12), and to 2 subgroups: spontaneous calving (n = 22) and assisted calving (n = 22). We observed that obstetric assistance was beneficial when calving lasted more than 4 h, because 100% of assisted calves had a high Apgar score (≥7) at 5 min, similar to that of spontaneously born calves after 2 h of calving. Rectal temperature of all calves remained within normal values, albeit with a reduction at 20 min of life. Calves born after a calving time >4 h had the highest rectal temperatures, especially those that required obstetrical assistance. There was a progressive increase in blood oxygenation with time, but calves in the >4 h group showed the highest partial pressure of carbon dioxide at birth, whereas calves in the 2 h and 2-4 h groups had lower values. A decrease in partial pressure of CO2 was observed at 120 min in the 2-4 h and >4 h groups. In the 2-4 h group, calves with obstetrical assistance had higher oxidative stress (measured as thiobarbituric acid reactive substances, TBARS) at 120 min of life compared with that at birth. In spontaneously born calves, TBARS increased only after 240 min. In the >4 h group, TBARS increased progressively with time, regardless of obstetrical subgroup. Calves born spontaneously within the 2 h group had higher TBARS values at birth than calves in the >4 h group with obstetrical assistance. Calves in the >4 h group showed higher levels of glutathione peroxidase (an antioxidant enzyme) at birth than those in the remaining groups. Glutathione peroxidase decreased at 120 min in the >4 h group and at 240 min for the 2 h and 2-4 h groups. In conclusion, obstetric assistance did not improve neonatal vitality and blood oxygenation when calving lasted less than 2 h. Calves born after 2 h of calving showed decreased vitality, hypercapnia, hypoxemia, and increased antioxidant status (glutathione peroxidase).
Collapse
Affiliation(s)
- Camila I Vannucchi
- Department of Animal Reproduction, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, SP, Brazil 05508-270.
| | - Liege G Silva
- Department of Animal Reproduction, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, SP, Brazil 05508-270
| | - Cristina F Lúcio
- Department of Animal Reproduction, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, SP, Brazil 05508-270
| | - Gisele A L Veiga
- Department of Animal Reproduction, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, SP, Brazil 05508-270
| |
Collapse
|
7
|
Sortica da Costa C, Placek MM, Czosnyka M, Cabella B, Kasprowicz M, Austin T, Smielewski P. Complexity of brain signals is associated with outcome in preterm infants. J Cereb Blood Flow Metab 2017; 37:3368-3379. [PMID: 28075691 PMCID: PMC5624386 DOI: 10.1177/0271678x16687314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A characteristic feature of complex healthy biological systems is the ability to react and adapt to minute changes in the environment. This 'complexity' manifests itself in highly irregular patterns of various physiological measurements. Here, we apply Multiscale Entropy (MSE) analysis to assess the complexity of systemic and cerebral near-infrared spectroscopy (NIRS) signals in a cohort of 61 critically ill preterm infants born at median (range) gestational age of 26 (23-31) weeks, before 24 h of life. We further correlate the complexity of these parameters with brain injury and mortality. Lower complexity index (CoI) of oxygenated haemoglobin (HbO2), deoxygenated haemoglobin (Hb) and tissue oxygenation index (TOI) were observed in those infants who developed intraventricular haemorrhage (IVH) compared to those who did not (P = 0.002, P = 0.010 and P = 0.038, respectively). Mean CoI of HbO2, Hb and total haemoglobin index (THI) were lower in those infants who died compared to those who survived (P = 0.012, P = 0.004 and P = 0.003, respectively). CoI-HbO2 was an independent predictor of IVH (P = 0.010). Decreased complexity of brain signals was associated with mortality and brain injury. Measurement of brain signal complexity in preterm infants is feasible and could represent a significant advance in the brain-oriented care.
Collapse
Affiliation(s)
| | - Michal M Placek
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Magdalena Kasprowicz
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Topun Austin
- 1 The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter Smielewski
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
8
|
Agostinelli A, Sbrollini A, Burattini L, Fioretti S, Di Nardo F, Burattini L. Noninvasive Fetal Electrocardiography Part II: Segmented-Beat Modulation Method for Signal Denoising. Open Biomed Eng J 2017; 11:25-35. [PMID: 28567129 PMCID: PMC5418918 DOI: 10.2174/1874120701711010025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/30/2016] [Accepted: 01/26/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Fetal well-being evaluation may be accomplished by monitoring cardiac activity through fetal electrocardiography. Direct fetal electrocardiography (acquired through scalp electrodes) is the gold standard but its invasiveness limits its clinical applicability. Instead, clinical use of indirect fetal electrocardiography (acquired through abdominal electrodes) is limited by its poor signal quality. Objective: Aim of this study was to evaluate the suitability of the Segmented-Beat Modulation Method to denoise indirect fetal electrocardiograms in order to achieve a signal-quality at least comparable to the direct ones. Method: Direct and indirect recordings, simultaneously acquired from 5 pregnant women during labor, were filtered with the Segmented-Beat Modulation Method and correlated in order to assess their morphological correspondence. Signal-to-noise ratio was used to quantify their quality. Results: Amplitude was higher in direct than indirect fetal electrocardiograms (median:104 µV vs. 22 µV; P=7.66·10-4), whereas noise was comparable (median:70 µV vs. 49 µV, P=0.45). Moreover, fetal electrocardiogram amplitude was significantly higher than affecting noise in direct recording (P=3.17·10-2) and significantly in indirect recording (P=1.90·10-3). Consequently, signal-to-noise ratio was initially higher for direct than indirect recordings (median:3.3 dB vs. -2.3 dB; P=3.90·10-3), but became lower after denoising of indirect ones (median:9.6 dB; P=9.84·10-4). Eventually, direct and indirect recordings were highly correlated (median: ρ=0.78; P<10-208), indicating that the two electrocardiograms were morphologically equivalent. Conclusion: Segmented-Beat Modulation Method is particularly useful for denoising of indirect fetal electrocardiogram and may contribute to the spread of this noninvasive technique in the clinical practice.
Collapse
Affiliation(s)
- Angela Agostinelli
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Agnese Sbrollini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Burattini
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Fioretti
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Francesco Di Nardo
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Laura Burattini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| |
Collapse
|
9
|
van ’t Hooft J, Vink M, Opmeer BC, Ensing S, Kwee A, Mol BWJ. ST-analysis in electronic foetal monitoring is cost-effective from both the maternal and neonatal perspective. J Matern Fetal Neonatal Med 2016; 29:3260-5. [DOI: 10.3109/14767058.2015.1126820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
10
|
Abstract
BACKGROUND Hypoxaemia during labour can alter the shape of the fetal electrocardiogram (ECG) waveform, notably the relation of the PR to RR intervals, and elevation or depression of the ST segment. Technical systems have therefore been developed to monitor the fetal ECG during labour as an adjunct to continuous electronic fetal heart rate monitoring with the aim of improving fetal outcome and minimising unnecessary obstetric interference. OBJECTIVES To compare the effects of analysis of fetal ECG waveforms during labour with alternative methods of fetal monitoring. SEARCH METHODS The Cochrane Pregnancy and Childbirth Group's Trials Register (latest search 23 September 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing fetal ECG waveform analysis with alternative methods of fetal monitoring during labour. DATA COLLECTION AND ANALYSIS One review author independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. One review author assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Seven trials (27,403 women) were included: six trials of ST waveform analysis (26,446 women) and one trial of PR interval analysis (957 women). The trials were generally at low risk of bias for most domains and the quality of evidence for ST waveform analysis trials was graded moderate to high. In comparison to continuous electronic fetal heart rate monitoring alone, the use of adjunctive ST waveform analysis made no obvious difference to primary outcomes: births by caesarean section (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.96 to 1.08; six trials, 26,446 women; high quality evidence); the number of babies with severe metabolic acidosis at birth (cord arterial pH less than 7.05 and base deficit greater than 12 mmol/L) (average RR 0.72, 95% CI 0.43 to 1.20; six trials, 25,682 babies; moderate quality evidence); or babies with neonatal encephalopathy (RR 0.61, 95% CI 0.30 to 1.22; six trials, 26,410 babies; high quality evidence). There were, however, on average fewer fetal scalp samples taken during labour (average RR 0.61, 95% CI 0.41 to 0.91; four trials, 9671 babies; high quality evidence) although the findings were heterogeneous and there were no data from the largest trial (from the USA). There were marginally fewer operative vaginal births (RR 0.92, 95% CI 0.86 to 0.99; six trials, 26,446 women); but no obvious difference in the number of babies with low Apgar scores at five minutes or babies requiring neonatal intubation, or babies requiring admission to the special care unit (RR 0.96, 95% CI 0.89 to 1.04, six trials, 26,410 babies; high quality evidence). There was little evidence that monitoring by PR interval analysis conveyed any benefit of any sort. AUTHORS' CONCLUSIONS The modest benefits of fewer fetal scalp samplings during labour (in settings in which this procedure is performed) and fewer instrumental vaginal births have to be considered against the disadvantages of needing to use an internal scalp electrode, after membrane rupture, for ECG waveform recordings. We found little strong evidence that ST waveform analysis had an effect on the primary outcome measures in this systematic review.There was a lack of evidence showing that PR interval analysis improved any outcomes; and a larger future trial may possibly demonstrate beneficial effects.There is little information about the value of fetal ECG waveform monitoring in preterm fetuses in labour. Information about long-term development of the babies included in the trials would be valuable.
Collapse
Affiliation(s)
- James P Neilson
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | | |
Collapse
|
11
|
Lutomski JE, Meaney S, Greene RA, Ryan AC, Devane D. Expert systems for fetal assessment in labour. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd010708.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jennifer E Lutomski
- National Perinatal Epidemiology Centre; 5th Floor, Cork University Maternity Hospital Wilton Cork Ireland
| | - Sarah Meaney
- National Perinatal Epidemiology Centre; 5th Floor, Cork University Maternity Hospital Wilton Cork Ireland
| | - Richard A Greene
- National Perinatal Epidemiology Centre; Department of Obstetrics and Gynaecology; 5th Floor, Cork University Maternity Hospital Wilton Cork Ireland
| | - Anthony C Ryan
- Cork University Maternity Hospital; Neonatology; Wilton Cork Ireland
| | - Declan Devane
- National University of Ireland Galway; School of Nursing and Midwifery; University Road Galway Ireland
| |
Collapse
|
12
|
Agostinelli A, Grillo M, Biagini A, Giuliani C, Burattini L, Fioretti S, Di Nardo F, Giannubilo SR, Ciavattini A, Burattini L. Noninvasive fetal electrocardiography: an overview of the signal electrophysiological meaning, recording procedures, and processing techniques. Ann Noninvasive Electrocardiol 2015; 20:303-13. [PMID: 25640061 DOI: 10.1111/anec.12259] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Noninvasive fetal electrocardiography (fECG), obtained positioning electrodes on the maternal abdomen, is important in safeguarding the life and the health of the unborn child. This study aims to provide a review of the state of the art of fECG, and includes a description of the parameters useful for fetus clinical evaluation; of the fECG recording procedures; and of the techniques to extract the fECG signal from the abdominal recordings. METHODS The fetus clinical status is inferred by analyzing growth parameters, supraventricular arrhythmias, ST-segment variability, and fetal-movement parameters from the fECG signal. This can be extracted from an abdominal recording obtained using one of the following two electrode-types configurations: pure-abdominal and mixed. Differently from the former, the latter also provides pure maternal ECG tracings. From a mathematical point of view, the abdominal recording is a summation of three signal components: the fECG signal (i.e., the signal of interest to be extracted), the abdominal maternal ECG (amECG), and the noise. Automatic extraction of fECG includes noise removal by abdominal signal prefiltration (0.5-45 Hz bandpass filter) and amECG cancellation. CONCLUSIONS Differences among methods rely on different techniques used to extract fECG. If pure abdominal electrode configurations are used, fECG is extracted directly from the abdominal recording using independent component analysis or template subtraction. Eventually, if mixed electrode configurations are used, the fECG can be extracted using the adaptive filtering fed with the maternal ECG recorded by the electrodes located in the woman thorax or shoulder.
Collapse
Affiliation(s)
- Angela Agostinelli
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| | - Marla Grillo
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| | - Alessandra Biagini
- Department of Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Corrado Giuliani
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| | - Luca Burattini
- United Hospitals "G. Salesi," Obstetrics and Gynecology Division, Ancona, Italy
| | - Sandro Fioretti
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Di Nardo
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| | - Stefano R Giannubilo
- Department of Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Ciavattini
- Department of Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Laura Burattini
- Department of Information Engineering, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
13
|
Becker JH, Krikhaar A, Schuit E, Mårtendal A, Maršál K, Kwee A, Visser GHA, Amer-Wåhlin I. The added predictive value of biphasic events in ST analysis of the fetal electrocardiogram for intrapartum fetal monitoring. Acta Obstet Gynecol Scand 2014; 94:175-82. [PMID: 25421390 DOI: 10.1111/aogs.12548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 11/20/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the predictive value of biphasic ST-events for interventions for suspected fetal distress and adverse neonatal outcome, when using ST-analysis of the fetal electrocardiogram (FECG) for intrapartum fetal monitoring. DESIGN Prospective cohort study. SETTING Three academic hospitals in Sweden. POPULATION Women in labor with a high-risk singleton fetus in cephalic position beyond 36 weeks of gestation. METHODS In women in labor who were monitored with conventional cardiotocography, ST-waveform analysis was recorded and concealed. Traces with biphasic ST-events of the FECG (index) were compared with traces without biphasic events of the FECG. The ability of biphasic events to predict interventions for suspected fetal distress and adverse outcome was assessed using univariable and multivariable logistic regression analyses. MAIN OUTCOME MEASURES Interventions for suspected fetal distress and adverse outcome (defined as presence of metabolic acidosis (i.e. umbilical cord pH <7.05 and base deficit in extracellular fluid >12 mmol), umbilical cord pH <7.00, 5-min Apgar score <7, admittance to neonatal intensive care unit or perinatal death). RESULTS Although the presence of biphasic events of the FECG was associated with more interventions for fetal distress and an increased risk of adverse outcome compared with cases with no biphasic events, the presence of significant (i.e. intervention advised according to cardiotocography interpretation) biphasic events showed no independent association with interventions for fetal distress [odds ratio (OR) 1.71, 95% confidence interval (CI) 0.65-4.50] or adverse outcome (OR 1.96, 95% CI 0.74-5.24). CONCLUSION The presence of significant biphasic events did not discriminate in the prediction of interventions for fetal distress or adverse outcome. Therefore, biphasic events in relation to ST-analysis monitoring during birth should be omitted if future studies confirm our findings.
Collapse
Affiliation(s)
- Jeroen H Becker
- Department of Obstetrics and Gynecology, Zuwe Hofpoort Hospital, Woerden, the Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Kessler J, Moster D, Albrechtsen S. Delay in intervention increases neonatal morbidity in births monitored with cardiotocography and ST-waveform analysis. Acta Obstet Gynecol Scand 2013; 93:175-81. [DOI: 10.1111/aogs.12304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 11/10/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Jörg Kessler
- Department of Obstetrics and Gynecology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; Clinical Fetal Physiology Research Group; University of Bergen; Bergen Norway
| | - Dag Moster
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Pediatrics; Haukeland University Hospital; Bergen Norway
- Department of Public Health and Primary Health Care; University of Bergen; Bergen Norway
| | - Susanne Albrechtsen
- Department of Obstetrics and Gynecology; Haukeland University Hospital; Bergen Norway
| |
Collapse
|
15
|
Electronic fetal monitoring in the United States: temporal trends and adverse perinatal outcomes. Obstet Gynecol 2013; 121:927-933. [PMID: 23635727 DOI: 10.1097/aog.0b013e318289510d] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality. METHODS We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use. RESULTS Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures. CONCLUSIONS The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE II.
Collapse
|
16
|
Abstract
BACKGROUND Hypoxaemia during labour can alter the shape of the fetal electrocardiogram (ECG) waveform, notably the relation of the PR to RR intervals, and elevation or depression of the ST segment. Technical systems have therefore been developed to monitor the fetal ECG during labour as an adjunct to continuous electronic fetal heart rate monitoring with the aim of improving fetal outcome and minimising unnecessary obstetric interference. OBJECTIVES To compare the effects of analysis of fetal ECG waveforms during labour with alternative methods of fetal monitoring. SEARCH METHODS The Cochrane Pregnancy and Childbirth Group's Trials Register (latest search 12 February 2013). SELECTION CRITERIA Randomised trials comparing fetal ECG waveform analysis with alternative methods of fetal monitoring during labour. DATA COLLECTION AND ANALYSIS Trial quality assessment and data extraction were performed by one review author, without blinding. MAIN RESULTS Six trials (16,295 women) were included: five trials of ST waveform analysis (15,338 women) and one trial of PR interval analysis (957 women). In comparison to continuous electronic fetal heart rate monitoring alone, the use of adjunctive ST waveform analysis made no significant difference to primary outcomes: births by caesarean section (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08), the number of babies with severe metabolic acidosis at birth (cord arterial pH less than 7.05 and base deficit greater than 12 mmol/L) (RR 0.78, 95% CI 0.44 to 1.37, data from 14,574 babies), or babies with neonatal encephalopathy (RR 0.54, 95% CI 0.24 to 1.25). There were, however, on average fewer fetal scalp samples taken during labour (RR 0.61, 95% CI 0.41 to 0.91) although the findings were heterogeneous; there were fewer operative vaginal deliveries (RR 0.89, 95% CI 0.81 to 0.98) and admissions to special care unit (RR 0.89, 95% CI 0.81 to 0.99); there was no statistically significant difference in the number of babies with low Apgar scores at five minutes or babies requiring neonatal intubation. There was little evidence that monitoring by PR interval analysis conveyed any benefit. AUTHORS' CONCLUSIONS These findings provide some modest support for the use of fetal ST waveform analysis when a decision has been made to undertake continuous electronic fetal heart rate monitoring during labour. However, the advantages need to be considered along with the disadvantages of needing to use an internal scalp electrode, after membrane rupture, for ECG waveform recordings.
Collapse
Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
| |
Collapse
|
17
|
Schuit E, Amer-Wahlin I, Ojala K, Vayssière C, Westerhuis ME, Maršál K, Tekay A, Saade GR, Visser GH, Groenwold RH, Moons KG, Mol BWJ, Kwee A. Effectiveness of electronic fetal monitoring with additional ST analysis in vertex singleton pregnancies at >36 weeks of gestation: an individual participant data metaanalysis. Am J Obstet Gynecol 2013; 208:187.e1-187.e13. [PMID: 23333546 DOI: 10.1016/j.ajog.2013.01.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/07/2013] [Accepted: 01/14/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the effectiveness of electronic fetal monitoring (EFM) alone and with additional ST analysis (EFM + ST) in laboring women with a singleton term pregnancy that is in cephalic presentation in the prevention of metabolic acidosis by the application of individual patient data metaanalysis. STUDY DESIGN We conducted an individual patient data metaanalysis using data from 4 randomized trials, which enabled us to account for missing data and investigate relevant subgroups. The primary outcome was metabolic acidosis, which was defined as an umbilical cord-artery pH <7.05 and a base deficit that had been calculated in the extra cellular fluid compartment >12 mmol/L. We performed 8 explanatory subgroup analyses for 8 different endpoints. RESULTS We analyzed data from 12,987 women and their newborn infants. Metabolic acidosis was present in 57 women (0.9%) in the EFM + ST group and 73 women (1.1%) in the EFM alone group (relative risk [RR], 0.76; 95% CI, 0.53-1.10). Compared with EFM alone, the use of EFM + ST resulted in a reduction in the frequency of instrumental vaginal deliveries (RR, 0.90; 95% CI, 0.83-0.99) and fetal blood samples (RR, 0.49; 95% CI, 0.44-0.55). Cesarean delivery rates were comparable between both groups (RR, 0.99; 95% CI, 0.91-1.09). Subgroup analyses showed that EFM + ST resulted in fewer admissions to a neonatal intensive care unit for women with a duration of pregnancy of >41 weeks (RR, 0.61; 95% CI, 0.39-0.95). CONCLUSION EFM + ST does not reduce the risk of metabolic acidosis, but it does reduce the need for instrumental vaginal deliveries and fetal blood sampling.
Collapse
|
18
|
KESSLER JÖRG, MOSTER DAG, ALBRECHTSEN SUSANNE. Intrapartum monitoring of high-risk deliveries with ST analysis of the fetal electrocardiogram: an observational study of 6010 deliveries. Acta Obstet Gynecol Scand 2013; 92:75-84. [DOI: 10.1111/j.1600-0412.2012.01528.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 07/26/2012] [Indexed: 01/08/2023]
|
19
|
SALMELIN ANETTE, WIKLUND INGELA, BOTTINGA ROGER, BRORSSON BENGT, EKMAN-ORDEBERG GUNVOR, GRIMFORS EVAENEROTH, HANSON ULF, BLOM MAY, PERSSON ELISABETH. Fetal monitoring with computerized ST analysis during labor: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2012; 92:28-39. [DOI: 10.1111/aogs.12009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
|
21
|
WESTERHUIS MICHELLEE, PORATH MARTINAM, BECKER JEROENH, VAN DEN AKKER ELINES, VAN BEEK ERIK, VAN DESSEL HENDRIKUSJ, DROGTROP ADDYP, VAN GEIJN HERMANP, GRAZIOSI GIUSEPPIC, GROENENDAAL FLORIS, VAN LITH JANM, MOL BENWILLEMJ, MOONS KARELG, NIJHUIS JANG, OEI SWANG, OOSTERBAAN HERMANP, RIJNDERS ROBBERTJ, SCHUITEMAKER NICOW, WIJNBERGER LIAD, WILLEKES CHRISTINE, WOUTERS MAURICEG, VISSER GERARDH, KWEE ANNEKE. Identification of cases with adverse neonatal outcome monitored by cardiotocography versus ST analysis: secondary analysis of a randomized trial. Acta Obstet Gynecol Scand 2012; 91:830-7. [DOI: 10.1111/j.1600-0412.2012.01431.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
22
|
Abstract
BACKGROUND Hypoxaemia during labour can alter the shape of the fetal electrocardiogram (ECG) waveform, notably the relation of the PR to RR intervals, and elevation or depression of the ST segment. Technical systems have therefore been developed to monitor the fetal ECG during labour as an adjunct to continuous electronic fetal heart rate monitoring with the aim of improving fetal outcome and minimising unnecessary obstetric interference. OBJECTIVES To compare the effects of analysis of fetal ECG waveforms during labour with alternative methods of fetal monitoring. SEARCH METHODS The Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2012). SELECTION CRITERIA Randomised trials comparing fetal ECG waveform analysis with alternative methods of fetal monitoring during labour. DATA COLLECTION AND ANALYSIS Trial quality assessment and data extraction were performed by one review author, without blinding. MAIN RESULTS Six trials (16,295 women) were included: five trials of ST waveform analysis (15,338 women) and one trial of PR interval analysis (957 women). In comparison to continuous electronic fetal heart rate monitoring alone, the use of adjunctive ST waveform analysis made no significant difference to primary outcomes: births by caesarean section (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08), the number of babies with severe metabolic acidosis at birth (cord arterial pH less than 7.05 and base deficit greater than 12 mmol/L) (RR 0.78, 95% CI 0.44 to 1.37, data from 14,574 babies), or babies with neonatal encephalopathy (RR 0.54, 95% CI 0.24 to 1.25). There were, however, on average fewer fetal scalp samples taken during labour (RR 0.61, 95% CI 0.41 to 0.91) although the findings were heterogeneous; there were fewer operative vaginal deliveries (RR 0.90, 95% CI 0.81 to 0.98) and admissions to special care unit (RR 0.89, 95% CI 0.81 to 0.99); there was no statistically significant difference in the number of babies with low Apgar scores at five minutes or babies requiring neonatal intubation. There was little evidence that monitoring by PR interval analysis conveyed any benefit. AUTHORS' CONCLUSIONS These findings provide some modest support for the use of fetal ST waveform analysis when a decision has been made to undertake continuous electronic fetal heart rate monitoring during labour. However, the advantages need to be considered along with the disadvantages of needing to use an internal scalp electrode, after membrane rupture, for ECG waveform recordings.
Collapse
Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
| |
Collapse
|
23
|
Abstract
UNLABELLED Following a perinatal hypoxic-ischaemic insult, term infants commonly develop cardiovascular dysfunction. Troponin-T, troponin-I and brain natriuretic peptide are sensitive indicators of myocardial compromise. The long-term effects of cardiovascular dysfunction on neurodevelopmental outcome following perinatal hypoxic ischaemia remain controversial. Follow-up studies are warranted to ensure optimal cardiac function in adulthood. CONCLUSION Cardiac biomarkers may improve the diagnosis of myocardial injury, help guide management, estimate mortality risk and may also aid in longterm neurodevelopmental outcome prediction following neonatal hypoxic-ischaemia.
Collapse
Affiliation(s)
- D Sweetman
- Neonatology, National Maternity Hospital, Dublin, Ireland.
| | | | | | | |
Collapse
|
24
|
Amer‐Wåhlin I, Kjellmer I, Maršál K, Olofsson P, Rosén KG. Cardiotocography and ST analysis for intrapartum fetal monitoring. Acta Obstet Gynecol Scand 2012. [DOI: 10.1111/j.1600-0412.2011.01319.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Isis Amer‐Wåhlin
- Department of Women and Child Health, Karolinska Institute, Stockholm
| | | | - Karel Maršál
- Department of Obstetrics and Gynecology, Clinical Sciences Lund, Lund University, Lund
| | - Per Olofsson
- Department of Obstetrics and Gynecology, Clinical Sciences Malmö, Lund University, Lund
| | | |
Collapse
|
25
|
AMER-WÅHLIN ISIS, KJELLMER INGEMAR, MARŠÁL KAREL, OLOFSSON PER, ROSÉN KARLGUSTAF. Swedish randomized controlled trial of cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram revisited: analysis of data according to standard versus modified intention-to-treat principle. Acta Obstet Gynecol Scand 2011; 90:990-6. [DOI: 10.1111/j.1600-0412.2011.01203.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
26
|
Chen HY, Chauhan SP, Ananth CV, Vintzileos AM, Abuhamad AZ. Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States. Am J Obstet Gynecol 2011; 204:491.e1-10. [PMID: 21752753 DOI: 10.1016/j.ajog.2011.04.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 03/22/2011] [Accepted: 04/13/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine the association between electronic fetal heart rate monitoring and neonatal and infant mortality, as well as neonatal morbidity. STUDY DESIGN We used the United States 2004 linked birth and infant death data. Multivariable log-binomial regression models were fitted to estimate risk ratio for association between electronic fetal heart rate monitoring and mortality, while adjusting for potential confounders. RESULTS In 2004, 89% of singleton pregnancies had electronic fetal heart rate monitoring. Electronic fetal heart rate monitoring was associated with significantly lower infant mortality (adjusted relative risk, 0.75); this was mainly driven by the lower risk of early neonatal mortality (adjusted relative risk, 0.50). In low-risk pregnancies, electronic fetal heart rate monitoring was associated with decreased risk for Apgar scores <4 at 5 minutes (relative risk, 0.54); in high-risk pregnancies, with decreased risk of neonatal seizures (relative risk, 0.65). CONCLUSION In the United States, the use of electronic fetal heart rate monitoring was associated with a substantial decrease in early neonatal mortality and morbidity that lowered infant mortality.
Collapse
|
27
|
Vijgen SMC, Westerhuis MEMH, Opmeer BC, Visser GHA, Moons KGM, Porath MM, Oei GS, Van Geijn HP, Bolte AC, Willekes C, Nijhuis JG, Van Beek E, Graziosi GCM, Schuitemaker NWE, Van Lith JMM, Van Den Akker ESA, Drogtrop AP, Van Dessel HJHM, Rijnders RJP, Oosterbaan HP, Mol BWJ, Kwee A. Cost-effectiveness of cardiotocography plus ST analysis of the fetal electrocardiogram compared with cardiotocography only. Acta Obstet Gynecol Scand 2011; 90:772-8. [PMID: 21446929 DOI: 10.1111/j.1600-0412.2011.01138.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of addition of ST analysis of the fetal electrocardiogram (ECG; STAN) to cardiotocography (CTG) for fetal surveillance during labor compared with CTG only. DESIGN Cost-effectiveness analysis based on a randomized clinical trial on ST analysis of the fetal ECG. SETTING Obstetric departments of three academic and six general hospitals in The Netherlands. Population. Laboring women with a singleton high-risk pregnancy, a fetus in cephalic presentation, a gestational age >36 weeks and an indication for internal electronic fetal monitoring. METHODS A trial-based cost-effectiveness analysis was performed from a health-care provider perspective. MAIN OUTCOME MEASURES Primary health outcome was the incidence of metabolic acidosis measured in the umbilical artery. Direct medical costs were estimated from start of labor to childbirth. Cost-effectiveness was expressed as costs to prevent one case of metabolic acidosis. RESULTS The incidence of metabolic acidosis was 0.7% in the ST-analysis group and 1.0% in the CTG-only group (relative risk 0.70; 95% confidence interval 0.38-1.28). Per delivery, the mean costs per patient of CTG plus ST analysis (n= 2 827) were €1,345 vs. €1,316 for CTG only (n= 2 840), with a mean difference of €29 (95% confidence interval -€9 to €77) until childbirth. The incremental costs of ST analysis to prevent one case of metabolic acidosis were €9 667. CONCLUSIONS The additional costs of monitoring by ST analysis of the fetal ECG are very limited when compared with monitoring by CTG only and very low compared with the total costs of delivery.
Collapse
Affiliation(s)
- Sylvia M C Vijgen
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Belfort MA, Saade GR. ST segment analysis as an adjunct to electronic fetal monitoring, Part I: background, physiology, and interpretation. Clin Perinatol 2011; 38:143-57, vii. [PMID: 21353095 DOI: 10.1016/j.clp.2010.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fetal electrocardiogram (ECG) ST segment analysis (STAN) was approved in 2005 in the United States as an adjunct to electronic fetal heart rate monitoring to determine whether obstetrical intervention is warranted when there is an increased risk for developing metabolic acidosis. STAN has utility in the reduction of fetal acidosis at birth, decreased need for fetal scalp blood sampling during labor, and decreased need for operative vaginal delivery and emergency cesarean delivery for fetal indications. This article discusses specific fetal ECG changes and their significance and the use of the STAN system.
Collapse
Affiliation(s)
- Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | | |
Collapse
|
29
|
Belfort MA, Saade GR. ST segment analysis (STAN) as an adjunct to electronic fetal monitoring, Part II: clinical studies and future directions. Clin Perinatol 2011; 38:159-67, vii. [PMID: 21353096 DOI: 10.1016/j.clp.2010.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Part 1 article focused on the physiology and general system for interpretation of ST segment analysis (STAN) systems. This article focuses on prior clinical studies of STAN and future research directions.
Collapse
Affiliation(s)
- Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | | |
Collapse
|
30
|
Boog G. [Cerebral palsy and perinatal asphyxia (II--Medicolegal implications and prevention)]. ACTA ACUST UNITED AC 2011; 39:146-73. [PMID: 21354846 DOI: 10.1016/j.gyobfe.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 01/18/2023]
Abstract
Obstetric litigation is a growing problem in developed countries and its escalating cost together with increasing medical insurance premiums is a major concern for maternity service providers, leading to obstetric practice cessation by many practitioners. Fifty-four to 74 % of claims are based on cardiotocographic (CTG) abnormalities and their interpretation followed by inappropriate or delayed reactions. A critical analysis is performed about the nine criteria identified by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their task force on Neonatal Encephalopathy and Cerebral Palsy: four essential criteria defining neonatal asphyxia and five other suggesting an acute intrapartum event sufficient to cause cerebral palsy in term newborns. The importance of placental histologic examination is emphasized in order to confirm sudden catastrophic events occurring before or during labor or to detect occult thrombotic processes affecting the fetal circulation, patterns of decreased placenta reserve and adaptative responses to chronic hypoxia. It may also exclude intrapartum hypoxia by revealing some histologic patterns typical of acute chorioamnionitis and fetal inflammatory response or compatible with metabolic diseases. Magnetic resonance imaging (MRI) of the infant's damaged brain is very contributive to elucidate the mechanism and timing of asphyxia in conjunction with the clinical picture, by locating cerebral injuries predominantly in white or grey matter. Intrapartum asphyxia is sometimes preventable by delivering weak fetuses by cesarean sections before birth, by avoiding some "sentinel" events, and essentially by responding appropriately to CTG anomalies and performing an efficient neonatal resuscitation. During litigation procedures, it is necessary to have access to a readable CTG, a well-documented partogram, a complete analysis of umbilical cord gases, a placental pathology and an extensive clinical work-up of the newborn infant including cerebral MRI. Malpractice litigation in obstetric care can be reduced by permanent CTG education, respect of national CTG guidelines, use of adjuncts such as fetal blood sampling for pH or lactates, regular review of adverse events in Clinical Risk Management (CRM) groups and periodic audits about low arterial cord pH in newborns, admission to neonatal unit, the need for assisted ventilation and the decision-to-delivery interval for emergency operative deliveries. Considering the fast occurrence of fetal cerebral hypoxic injuries, and thus despite an adequate management, many intrapartum asphyxias will not be preventable. Conversely, well-documented hypoxic-ischemic brain insults during the antenatal period do not automatically exclude intrapartum suboptimal obstetric care.
Collapse
Affiliation(s)
- G Boog
- Service de gynécologie-obstétrique, hôpital Mère-et-Enfant, CHU de Nantes, 38 boulevard Jean-Monnet, Nantes cedex 1, France.
| |
Collapse
|
31
|
Abstract
Since its introduction more than 40 years ago, electronic fetal monitoring has become widely used for intrapartum surveillance to determine fetal wellbeing in labor. Although fetal hypoxia and acidosis are reflected in changes in fetal heart rate, there is no evidence that cardiotocography has been effective in reducing neonatal morbidity related to fetal distress occurring during labor. Indeed the specificity of this tool is poor and in many instances the incorporation of electronic fetal monitoring into intrapartum care has merely led to an increase in medical intervention rather than an improvement in neonatal outcome. Fetal electrocardiography (ECG) analysis provides an additional method for assessing the response of the fetus to hypoxia and in particular to the development of metabolic acidosis. ST changes in the fetal ECG can be quantified with computational analysis, reducing subjective interpretation that has been problematic with traditional electronic fetal monitoring. Formal algorithms indicating appropriate points for intervention in labor have been designed. The fetal ECG has been shown to be a useful adjunct to traditional electronic fetal monitoring in several randomized controlled trials with evidence of reduced rates of neonatal encephalopathy and reduced rates of obstetric intervention.
Collapse
Affiliation(s)
- I Amer-Wåhlin
- Department of Women and Child Health, ALB Q2:7, Karolinska Institute, 171 76 Solna, Stockholm, Sweden.
| | | |
Collapse
|
32
|
Effects of post-resuscitation treatment with N-acetylcysteine on cardiac recovery in hypoxic newborn piglets. PLoS One 2010; 5:e15322. [PMID: 21203535 PMCID: PMC3006425 DOI: 10.1371/journal.pone.0015322] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 11/06/2010] [Indexed: 12/02/2022] Open
Abstract
Aims Although N-acetylcysteine (NAC) can decrease reactive oxygen species and improve myocardial recovery after ischemia/hypoxia in various acute animal models, little is known regarding its long-term effect in neonatal subjects. We investigated whether NAC provides prolonged protective effect on hemodynamics and oxidative stress using a surviving swine model of neonatal asphyxia. Methods and Results Newborn piglets were anesthetized and acutely instrumented for measurement of systemic hemodynamics and oxygen transport. Animals were block-randomized into a sham-operated group (without hypoxia-reoxygenation [H–R, n = 6]) and two H-R groups (2 h normocapnic alveolar hypoxia followed by 48 h reoxygenation, n = 8/group). All piglets were acidotic and in cardiogenic shock after hypoxia. At 5 min after reoxygenation, piglets were given either saline or NAC (intravenous 150 mg/kg bolus + 20 mg/kg/h infusion) via for 24 h in a blinded, randomized fashion. Both cardiac index and stroke volume of H-R controls remained lower than the pre-hypoxic values throughout recovery. Treating the piglets with NAC significantly improved cardiac index, stroke volume and systemic oxygen delivery to levels not different from those of sham-operated piglets. Accompanied with the hemodynamic improvement, NAC-treated piglets had significantly lower plasma cardiac troponin-I, myocardial lipid hydroperoxides, activated caspase-3 and lactate levels (vs. H-R controls). The change in cardiac index after H-R correlated with myocardial lipid hydroperoxides, caspase-3 and lactate levels (all p<0.05). Conclusions Post-resuscitation administration of NAC reduces myocardial oxidative stress and caused a prolonged improvement in cardiac function and in newborn piglets with H-R insults.
Collapse
|
33
|
Amer-Wåhlin I, Miller LA. ST analysis as an adjunct to electronic fetal monitoring: an overview. J Perinat Neonatal Nurs 2010; 24:231-7. [PMID: 20697240 DOI: 10.1097/jpn.0b013e3181ea13b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Conventional electronic fetal monitoring in the United States has value as a screening tool but is extremely limited as a diagnostic tool. ST analysis was developed as an adjunctive technology, able to measure changes in the ST segment of the fetal electrocardiogram during periods of hypoxia, improving the identification of the fetus at risk for metabolic acidemia at birth. Currently used only in a handful of hospitals in the United States, studies abroad have demonstrated that an integrated approach utilizing electronic fetal monitoring, ST analysis, and standardized guidelines in a selected patient population can improve neonatal outcome, decrease acidemia at birth, and decrease obstetric operative delivery. Research is needed to determine whether similar results are possible in the US population.
Collapse
Affiliation(s)
- Isis Amer-Wåhlin
- Institute of Women and Child Health, Karolinska Institute, Stockholm, Sweden
| | | |
Collapse
|
34
|
Norén H, Carlsson A. Reduced prevalence of metabolic acidosis at birth: an analysis of established STAN usage in the total population of deliveries in a Swedish district hospital. Am J Obstet Gynecol 2010; 202:546.e1-7. [PMID: 20079889 DOI: 10.1016/j.ajog.2009.11.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Revised: 08/26/2009] [Accepted: 11/18/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate quality-of-care improvements after the introduction of ST waveform analysis as an adjunct to standard cardiotocography (CTG). STUDY DESIGN This was a prospective clinical study that was conducted over 7 years. Four yearly cohorts of 12,832 term pregnancies were part of a detailed analysis. Cord blood metabolic acidosis and neonatal outcome were main outcome measures. RESULTS The STAN (S31 Fetal Heart Monitor; Neoventa Medical AB, Mölndal, Sweden) usage rate increased from 26 to 69%. The cord metabolic acidosis rate was reduced from 0.72 to 0.06%. This 91.7% improvement was associated with a significant reduction in the number of cases with a prolonged response time, calculated as the time from CTG + ST indications to intervene until delivery and an ability of the staff to identify and act on preterminal and unstable fetal heart rate patterns at the onset of a recording. CONCLUSION Our data indicate a paradigm shift in the outcome of delivery related to a high rate of CTG + ST usage and the application of structured CTG analysis.
Collapse
|
35
|
Kesselheim AS, November MT, Lifford KL, McElrath TF, Puopolo AL, Orav EJ, Studdert DM. Using malpractice claims to identify risk factors for neurological impairment among infants following non-reassuring fetal heart rate patterns during labour. J Eval Clin Pract 2010; 16:476-83. [PMID: 20482746 DOI: 10.1111/j.1365-2753.2009.01148.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We sought to use a novel case-selection methodology to identify antenatal or intrapartum risk factors associated with neonatal neurological impairment following non-reassuring fetal heart rate patterns during labour. METHOD We used a retrospective case-control design with bivariate and multivariate conditional logistic regression. Cases were births in which electronic fetal monitoring (EFM) showed non-reassuring patterns and the infant had neurological disability. Controls were births in which EFM was non-reassuring but the infant was born healthy. We identified 36 cases from among malpractice claims filed with a liability insurer in Massachusetts between 1985 and 2001 and randomly selected 70 controls, matching them to cases by hospital, birth date and gestational age. RESULTS More cases had maternal antenatal vaginal bleeding (P = 0.004), a prolonged latent phase or protracted dilation during the first stage of labour (P = 0.03), and protracted descent or prolonged second stage (P = 0.01). More cases also had minimal variability on EFM on admission (P = 0.02) and during the second stage (P = 0.02). Multivariate analysis highlighted three significant predictors of neurological injury following complicated labour: antenatal vaginal bleeding (OR = 27.1), prolonged latent phase or protracted dilation in the first stage (OR = 4.0) and EFM showing minimal variability in the first stage (OR = 4.3). CONCLUSION These promising initial findings suggest that future research into outcomes from complicated labour with non-reassuring heart rate patterns should focus on maternal history of vaginal bleeding, slow labour and minimal variability on EFM.
Collapse
Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA02120, USA.
| | | | | | | | | | | | | |
Collapse
|
36
|
Cardiotocography Plus ST Analysis of Fetal Electrocardiogram Compared With Cardiotocography Only for Intrapartum Monitoring. Obstet Gynecol 2010; 115:1173-1180. [DOI: 10.1097/aog.0b013e3181dfffd6] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
37
|
Kwee A, van der Hoorn-van den Beld CW, Veerman J, Dekkers AHS, Visser GHA. STAN® S21 fetal heart monitor for fetal surveillance during labor: an observational study in 637 patients. J Matern Fetal Neonatal Med 2010; 15:400-7. [PMID: 15280112 DOI: 10.1080/14767050410001727404] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the value of the STAN fetal heart monitor for intrapartum fetal monitoring using cardiotocography (CTG) and fetal electrocardiography (ECG). DESIGN Prospective observational study. MATERIAL AND METHODS Between August 2000 and November 2002, 637 high-risk labors were monitored using a STAN S21 fetal heart monitor, providing CTG plus automatic ST analysis of the fetal ECG. Guidelines with recommendations about when to intervene were available. During the study period labor-ward personnel were systematically instructed about the (patho)-physiology of asphyxia and CTG and ST changes during labor. RESULTS Four hundred and forty-nine recordings were available for analysis of outcome in relation to ST changes. In 61 cases, ST changes requiring intervention occurred > 10 min before birth. In 35 (57%) of these cases, umbilical artery blood pH at delivery was < 7.15. Eighteen (4.0%) neonates were born with metabolic acidosis (umbilical artery pH < 7.05 and extracellular base deficit > 12 mmol/l). Significant ST changes (18-31 min before birth) were present in all five cases with pH < 7.00 and in six of the 13 cases with pH of 7.00-7.04 (false-negative rate 1.6%). Neonatal follow-up showed no adverse outcome. One hundred and ninety-two fetal blood samples (121 in the first stage and 71 in the second stage of labor) were taken from 142 women. Fetal scalp blood pH was < 7.15 in ten samples, 7.15-7.19 in 11 samples, 7.20-7.24 in 30 samples and > or =7.25 in 141 samples. ST changes occurred in eight (80%), six (55%), nine (30%) and 15 (11%) of these cases, respectively. In 188 (29.5%) women, outcome could not be analyzed in relation to ST changes because of inadequate recording (time between end of recording and delivery > 20 min or poor signal quality) or the absence of umbilical cord gases. In this group, four (2.1%) neonates with metabolic acidosis were born. In three of these cases the fetal ECG signal was of was poor quality and in one case the recording had ended 60 min before birth. CONCLUSION ST changes were present in all five cases with severe metabolic acidosis (umbilical artery pH < 7.00). ST changes occurred in 46% of cases with mild metabolic acidosis. CTG plus ST analysis was more specific in detecting fetal acidemia than CTG alone.
Collapse
Affiliation(s)
- A Kwee
- Dept. of Obstetrics and Gynecology, University Medical Center Utrecht, Linflaan 6, 3584 EA Utrecht, The Netherlands
| | | | | | | | | |
Collapse
|
38
|
Gyselaers W, Indrato R, Westerhuis M, Visser G, Rosén K. STAN®-recorded intrapartum loss of beat-to-beat variation associated with prolonged QT-interval: Indicative for fetal hypocalcemia? J Matern Fetal Neonatal Med 2009; 20:69-73. [PMID: 17437203 DOI: 10.1080/02331930601128048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
39
|
Ross MG, Devoe LD, Rosen KG. ST-segment analysis of the fetal electrocardiogram improves fetal heart rate tracing interpretation and clinical decision making. J Matern Fetal Neonatal Med 2009; 15:181-5. [PMID: 15280144 DOI: 10.1080/14767050410001668284] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Since its introduction into clinical use, the efficacy of electronic fetal heart rate (FHR) monitoring (EFM) has been questionable. This has been due partly to the marked variation in interpretation of the FHR pattern and subsequent decisions for obstetric intervention, (e.g., the need for prompt delivery). Current application of EFM is limited to the assessment of FHR patterns and uterine contractions. Recent development of higher-order FHR analysis has yielded monitoring systems that can add automated fetal electrocardiographic ST segment analysis to the standard FHR and uterine contraction information. Our goal was to evaluate the effect of adding ST segment analysis to standard FHR information on observer agreement for clinical decision making. METHODS Seven practitioners who were trained and experienced in combined FHR and ST monitoring reviewed 51 fetal monitor tracings, ranging from 2 to 4 h in length. Reviews were conducted in two sessions and at different times. The first session presented only the FHR and uterine contraction information, following which the participants determined the time at which intervention (decision for operative vaginal or Cesarean section delivery) was indicated. In the second session, the participants were provided with a randomized sequence of the same tracings with the addition of ST segment information, as produced by the STAN monitor system (Neoventa Medical, Gothenburg, Sweden). Observer agreement was based on the proportion of participants who agreed on the need for an intervention, and the per cent agreement on the timing of the intervention within 20 min before or after the median time of intervention. RESULTS Of the 51 cases included in this study there were ten fetuses with umbilical artery (UA) pH between 7.05 and 7.14, and nine with UA pH of < 7.05. Observer agreement increased significantly for required intervention when the ST segment information was available for tracing analysis as compared with review of the standard tracing alone (0.96 vs. 0.80, p < 0.05) and the timing of intervention (0.92 vs. 0.66, respectively, p < 0.05). Similarly, correct identification for needed interventions on fetuses with abnormal outcomes increased from 86 to 93% while unneeded interventions on normal fetuses decreased from 43 to 6%. CONCLUSION The addition of ST analysis to standard FHR monitoring improves observer consistency in both the decision for and timing of obstetric interventions. The incorporation of ST segment data with the standard FHR tracing may reduce the number of unneeded obstetric interventions when fetal compromise is absent.
Collapse
Affiliation(s)
- M G Ross
- Department of Obstetrics and Gynecology, Harbor-UCLA Research and Education Institute, Torrance, California 90501, USA
| | | | | |
Collapse
|
40
|
Amer-Wåhlin I, Källén K, Herbst A, Rydhstroem H, Sundström AK, Marsál K. Implementation of new medical techniques: Experience from the Swedish randomized controlled trial on fetal ECG during labor. J Matern Fetal Neonatal Med 2009; 18:93-100. [PMID: 16203593 DOI: 10.1080/14767050500233191] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In a large Swedish multicenter randomized controlled trial (RCT) on intra partum fetal monitoring with automatic analysis of fetal ECG waveform (STAN) in combination with cardiotocography (CTG) (4966 parturients, 300 obstetricians and midwives managing the patients), interim analysis revealed protocol violations. By a post hoc analysis of the results over time, factors affecting the acceptance of the new technique were analyzed. METHODS The rates of primary and secondary outcome measures (fetal outcome, operative deliveries) were compared in the two study groups (CTG + ST and CTG only). Changes over time were statistically evaluated using a test for homogeneity between the two periods. RESULTS After retraining, the CTG + ST group showed the lowest rates of operative delivery for fetal distress, fetal blood sampling and admissions to neonatal intensive care unit. Operative deliveries (p = 0.02) and the number of fetal blood sampling decreased significantly over time (p = 0.001). CONCLUSIONS Training and education probably predisposed the clinicians to a change and reinforced it when it occurred as a result of increased personal experience. The audit and feedback together with the influence of opinion leaders and inter-collegial interactions seem to have been of importance for the successively increasing acceptance of the new method during the RCT.
Collapse
Affiliation(s)
- I Amer-Wåhlin
- Department of Obstetrics and Gynecology, Lund University Hospital, Lund, Sweden.
| | | | | | | | | | | |
Collapse
|
41
|
Heintz E, Brodtkorb TH, Nelson N, Levin LA. The long-term cost-effectiveness of fetal monitoring during labour: a comparison of cardiotocography complemented with ST analysis versus cardiotocography alone. BJOG 2009; 115:1676-87. [PMID: 19035942 PMCID: PMC2659360 DOI: 10.1111/j.1471-0528.2008.01935.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective To assess the cost-effectiveness of the use of cardiotocography (CTG) complemented with fetal electrocardiography and ST analysis compared with the use of CTG alone in term deliveries when a decision has been made to use fetal monitoring with a scalp electrode. Design A cost-effectiveness analysis based on a probabilistic decision model incorporating relevant strategies and lifelong outcomes. Setting Maternity wards in Sweden. Population Women with term fetuses after a clinical decision had been made to apply a fetal scalp electrode for internal CTG. Methods A decision model was used to compare the costs and effects of two different treatment strategies. Baseline estimates were derived from the literature. Discounted costs and quality-adjusted life years (QALYs) were simulated over a lifetime horizon using a probabilistic model. Main outcome measures QALYs, incremental costs, and cost per QALY gained expressed as incremental cost-effectiveness ratio (ICER). Results The analysis found an incremental effect of 0.005 QALYs for ST analysis compared with CTG; the ST analysis strategy was also moreover associated with a €56 decrease in costs, thus dominating the CTG strategy. The probability that ST analysis is cost-effective in comparison with CTG is high, irrespective of the willingness-to-pay value for a QALY. Conclusions Compared with CTG alone, ST analysis is cost-effective when used in term high-risk deliveries in which there is a need for internal fetal monitoring.
Collapse
Affiliation(s)
- E Heintz
- Center for Medical Technology Assessment (CMT), Linköping University, Linköping, Sweden.
| | | | | | | |
Collapse
|
42
|
Abstract
The last century has seen dramatic developments in medical care as technological advances have been applied to both diagnosis and treatment. Some areas of obstetrics have been slow to benefit from these advances – and none more so than the care of the fetus in labour.
Collapse
|
43
|
Blad S, Welin AK, Kjellmer I, Rosén K, Mallard C. ECG and Heart Rate Variability Changes in Preterm and Near-Term Fetal Lamb Following LPS Exposure. Reprod Sci 2008; 15:572-83. [DOI: 10.1177/1933719107314060] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sofia Blad
- Perinatal Center, Department of Neuroscience and Physiology,
| | | | - Ingemar Kjellmer
- Pediatrics, Sahlgrenska Academy, University of Gothenburg, Sweden
| | | | - Carina Mallard
- Perinatal Center, Department of Neuroscience and Physiology
| |
Collapse
|
44
|
Rault S, Vayssiere C, Roth E, David E, Favre R, Langer B. Assessment of STAN S21 fetal heart monitor by medical staff. Int J Gynaecol Obstet 2008; 102:8-11. [DOI: 10.1016/j.ijgo.2008.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 01/16/2008] [Accepted: 01/29/2008] [Indexed: 11/24/2022]
|
45
|
Oxymétrie, ECG fœtal et enregistrement informatisé (comparaison avec pH). ACTA ACUST UNITED AC 2008; 37 Suppl 1:S72-80. [DOI: 10.1016/j.jgyn.2007.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
46
|
Norén H, Luttkus AK, Stupin JH, Blad S, Arulkumaran S, Erkkola R, Luzietti R, Visser GHA, Yli B, Rosén KG. Fetal scalp pH and ST analysis of the fetal ECG as an adjunct to cardiotocography to predict fetal acidosis in labor--a multi-center, case controlled study. J Perinat Med 2007; 35:408-14. [PMID: 17685855 DOI: 10.1515/jpm.2007.097] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the relationship between scalp pH (FBS) and ST analysis in situations of acidosis with special emphasis on the timing of cardiotocography (CTG), FBS and ST changes during labor. STUDY DESIGN From a European Union multicenter study on clinical implementation of the STAN methodology, 911 cases were identified where a scalp-pH had been obtained. In 53 cases, marked cord artery acidosis was found (cord artery pH<7.06) and 44 cases showed moderate acidemia at birth (pH 7.06-7.09). Comparisons were made with 97 control cases (pH>or=7.20). RESULTS Of those cases with FHR+ST events recorded within 16 min of delivery, 61% (17/28) had a cord artery pH>or=7.20. The corresponding figure for cases where STAN indications occurred for more than 16 min was 19% (13/69) (OR 6.66, 2.53-17.55, P<0.001). Out of the 121 cases with an abnormal CTG, 84 (69%) showed a cord artery pH of <7.10. STAN indicated abnormality in 83% (70 out of 84). The corresponding figure for scalp pH<7.20 was 43% (36/84). In the case of CTG changes at the start of an adequate recording STAN guidelines provided information on developing acidosis in all cases but one (16 out of 17) in the marked acidosis group. STAN guidelines indicated abnormality prior to an abnormal FBS in 14 out of 17 cases. The median duration between STAN indications to intervention and an abnormal FBS was 29 (95% CI 11-74) min. CONCLUSIONS ST analysis, as an adjunct to CTG, identifies adverse fetal conditions during labor similar to that of FBS but on a more consistent basis. The timing of CTG+ST changes relates to the level of acidosis at birth.
Collapse
Affiliation(s)
- Håkan Norén
- Department of Obstetrics and Gynecology, Perinatal Center, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Doria V, Papageorghiou AT, Gustafsson A, Ugwumadu A, Farrer K, Arulkumaran S. Review of the first 1502 cases of ECG-ST waveform analysis during labour in a teaching hospital. BJOG 2007; 114:1202-7. [PMID: 17877672 DOI: 10.1111/j.1471-0528.2007.01480.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the impact of introduction of the STAN monitoring system. STUDY DESIGN Prospective observational study. SETTING Tertiary referral labour ward, St George's Hospital, London. POPULATION High-risk term pregnancies. METHODS We report all consecutive cases of intrapartum monitoring using the STAN S 21 fetal heart monitor. Cases with adverse neonatal outcome were evaluated in relation to the ST waveform analysis and cardiotocography (CTG). MAIN OUTCOME MEASURES Cord artery metabolic acidosis, neonatal encephalopathy (NNE) and reasons behind cases with poor outcome. RESULTS Between 2002 and 2005, there were 1502 women monitored by STAN. Based on combined STAN analysis in the 1502 women, action was indicated in 358 women (23.8%), while in 1108 women (73.8%) no action was indicated. Traces were not interpretable in 36 women (2.4%). Of the 836 cases (55.7%) where cord blood gases were available, there were 23 cases (2.8%) of metabolic acidosis and 16 of these (70%) were identified by STAN. Overall, there were 14 cases of NNE monitored by STAN. Retrospective analysis of these highlights human errors, such as poor CTG interpretation, delay in taking appropriate action and not following the guidelines. CONCLUSIONS Our experience suggests the need for more intense training on interpretation of CTG and strict adherence to guidelines.
Collapse
Affiliation(s)
- V Doria
- Clinical Developmental Sciences, Section of Obstetrics and Gynaecology, St George's University of London, London, UK
| | | | | | | | | | | |
Collapse
|
48
|
References. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007. [DOI: 10.1016/s1701-2163(16)32622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
49
|
Vayssière C, David E, Meyer N, Haberstich R, Sebahoun V, Roth E, Favre R, Nisand I, Langer B. A French randomized controlled trial of ST-segment analysis in a population with abnormal cardiotocograms during labor. Am J Obstet Gynecol 2007; 197:299.e1-6. [PMID: 17826428 DOI: 10.1016/j.ajog.2007.07.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 05/06/2007] [Accepted: 07/06/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess whether knowledge of ST-segment analysis was associated with a reduction in operative deliveries for nonreassuring fetal status (NRFS) or with a need for at least 1 scalp pH during labor. STUDY DESIGN Seven hundred ninety-nine women at term with abnormal cardiotocography or meconium-stained amniotic fluid (7%) were assigned randomly to the intervention group (cardiotocography + STAN) or the control group (cardiotocography) in 2 university hospitals in Strasbourg, France. Scalp pH testing was optional in both groups. Abnormal neonatal outcome was pH <7.05 or umbilical cord blood artery base deficit of >12 or a 5-min Apgar score of <7 or neonatal intensive care unit admission or convulsions or neonatal death. Study power was 80% for the detection of a prespecified reduction from 50%-40% in operative delivery for NRFS. RESULTS The operative delivery (cesarean or instrumental) rate for NRFS did not differ between the 2 groups: 33.6% (134/399) in the cardiotocography + STAN analysis group vs 37% (148/400) in the cardiotocography group (relative risk, 0.91; 95% CI, 0.75-1.10). The rate of operative delivery for dystocia was also similar in both groups. The percentage of women whose fetus had at least 1 scalp pH measurement during labor was substantially lower in the group with ST-segment analysis: 27% compared with 62% (relative risk, 0.44; 95% CI, 0.36-0.52). Neonatal outcomes did not differ significantly between groups. CONCLUSION In a population with abnormal cardiotocography in labor, cardiotocography combined with ST-segment analysis was not associated with a reduction in operative deliveries for NRFS. The proportion of infants without scalp pH sampling during labor increased substantially, however.
Collapse
Affiliation(s)
- Christophe Vayssière
- Department of Obstetrics and Gynecology, Centre Medico-Chirurgical et Obstétrical-SIHCUS, Strasbourg, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Westerhuis MEMH, Moons KGM, van Beek E, Bijvoet SM, Drogtrop AP, van Geijn HP, van Lith JMM, Mol BWJ, Nijhuis JG, Oei SG, Porath MM, Rijnders RJP, Schuitemaker NWE, van der Tweel I, Visser GHA, Willekes C, Kwee A. A randomised clinical trial on cardiotocography plus fetal blood sampling versus cardiotocography plus ST-analysis of the fetal electrocardiogram (STAN) for intrapartum monitoring. BMC Pregnancy Childbirth 2007; 7:13. [PMID: 17655764 PMCID: PMC1976105 DOI: 10.1186/1471-2393-7-13] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Accepted: 07/26/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiotocography (CTG) is worldwide the method for fetal surveillance during labour. However, CTG alone shows many false positive test results and without fetal blood sampling (FBS), it results in an increase in operative deliveries without improvement of fetal outcome. FBS requires additional expertise, is invasive and has often to be repeated during labour. Two clinical trials have shown that a combination of CTG and ST-analysis of the fetal electrocardiogram (ECG) reduces the rates of metabolic acidosis and instrumental delivery. However, in both trials FBS was still performed in the ST-analysis arm, and it is therefore still unknown if the observed results were indeed due to the ST-analysis or to the use of FBS in combination with ST-analysis. METHODS/DESIGN We aim to evaluate the effectiveness of non-invasive monitoring (CTG + ST-analysis) as compared to normal care (CTG + FBS), in a multicentre randomised clinical trial setting. Secondary aims are: 1) to judge whether ST-analysis of fetal electrocardiogram can significantly decrease frequency of performance of FBS or even replace it; 2) perform a cost analysis to establish the economic impact of the two treatment options. Women in labour with a gestational age > or = 36 weeks and an indication for CTG-monitoring can be included in the trial. Eligible women will be randomised for fetal surveillance with CTG and, if necessary, FBS or CTG combined with ST-analysis of the fetal ECG. The primary outcome of the study is the incidence of serious metabolic acidosis (defined as pH < 7.05 and Bdecf > 12 mmol/L in the umbilical cord artery). Secondary outcome measures are: instrumental delivery, neonatal outcome (Apgar score, admission to a neonatal ward), incidence of performance of FBS in both arms and cost-effectiveness of both monitoring strategies across hospitals. The analysis will follow the intention to treat principle. The incidence of metabolic acidosis will be compared across both groups. Assuming a reduction of metabolic acidosis from 3.5% to 2.1 %, using a two-sided test with an alpha of 0.05 and a power of 0.80, in favour of CTG plus ST-analysis, about 5100 women have to be randomised. Furthermore, the cost-effectiveness of CTG and ST-analysis as compared to CTG and FBS will be studied. DISCUSSION This study will provide data about the use of intrapartum ST-analysis with a strict protocol for performance of FBS to limit its incidence. We aim to clarify to what extent intrapartum ST-analysis can be used without the performance of FBS and in which cases FBS is still needed. TRIAL REGISTRATION NUMBER ISRCTN95732366.
Collapse
Affiliation(s)
- Michelle EMH Westerhuis
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, The Netherlands
| | - Karel GM Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Erik van Beek
- Department of Obstetrics and Gynaecology, Sint Antonius Hospital Nieuwegein, The Netherlands
| | - Saskia M Bijvoet
- Department of Obstetrics and Gynaecology, VU Medical Center Amsterdam, The Netherlands
| | - Addy P Drogtrop
- Department of Obstetrics and Gynaecology, Tweesteden Hospital Tilburg, The Netherlands
| | - Herman P van Geijn
- Department of Obstetrics and Gynaecology, VU Medical Center Amsterdam, The Netherlands
| | - Jan MM van Lith
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwen Gasthuis Amsterdam, The Netherlands
| | - Ben WJ Mol
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Maxima Medical Center Veldhoven, The Netherlands
| | - Jan G Nijhuis
- Department of Obstetrics and Gynaecology, Academic Medical Center Maastricht, The Netherlands
| | - S Guid Oei
- Department of Obstetrics and Gynaecology, Maxima Medical Center Veldhoven, The Netherlands
| | - Martina M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Center Veldhoven, The Netherlands
| | - Robbert JP Rijnders
- Department of Obstetrics and Gynaecology, Jeroen Bosch Medical Center 's Hertogenbosch, The Netherlands
| | - Nico WE Schuitemaker
- Department of Obstetrics and Gynaecology, Diakonessenhuis Utrecht, The Netherlands
| | | | - Gerard HA Visser
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, The Netherlands
| | - Christine Willekes
- Department of Obstetrics and Gynaecology, Academic Medical Center Maastricht, The Netherlands
| | - Anneke Kwee
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, The Netherlands
| |
Collapse
|